Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, November 05, 2009

Tweaking the Tail of the Home Birth Tiger

Science Blogs has a new contributor: Dr. Amy Tuteur, an OBGYN who elicits, shall we say, very strong reactions among her readers.

Dr. Amy's debut post trumpets "The Tragic Toll of Home Birth!" (The exclamation point isn't actually there, but doesn't it sound like it should be?) Reading through it, though, sounds more like a screed against midwives -- specifically those who are not CNMs (Certified Nurse Midwives) -- than home birth per se. She includes this nifty chart to demonstrate her point:

Let's see. According to these numbers, non-CNMs do indeed have higher neonatal mortality rates than either MDs or CMNs, however MDs have nearly double the mortality rate of CNMs! Wow. If I really want to be safe, I should go to a midwife.

Then again, that table doesn't actually say anything about home birth. It just breaks down mortality figures by birth attendant. As it happens, the database Dr. Amy links is ridiculously easy to navigate. (Go and play with it.) In fact, I was able to come up with this breakdown of home birth vs. hospital birth, by birth attendant, using the same remaining parameters as Dr. Amy (2003-2004; white women, 37+ weeks, ages 20-45):

[Sorry I can't manage it in a nifty table format]

In Hospital:
CNM: Deaths: 107, Births: 292,422, Deaths/1,000 births: 0.37
MDs: Deaths: 2,118, Births: 3,498,447, Deaths/1,000 births: 0.61
Other Midwives: Deaths: 2, Births: 4,323, Deaths/1,000 births: Suppressed

Not in Hospital:
CNM: Deaths: 6, Births: 11,853, Deaths/1,000 births: Suppressed
MD: Deaths: 7, Births: 2.689, Deaths/1,000 births: Suppressed
Other Midwives: Deaths: 20, Births: 16,613, Deaths/1,000 births: 1.20

(Note: Rates are suppressed when the numerator is less than 20, because the figure does not meet the NCHS standard of reliability or precision.)

Source: United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS), Linked Birth / Infant Death Records 2003-2005 on CDC WONDER On-line Database. Accessed at on Nov 5, 2009 11:45:58 AM

So what does this really mean? It means that a total of 33 babies who were born at home between 2003 and 2004 died in their first month of life. Yes, more of them had mothers who were attended by non-certified midwife than by a CNM or MD. By contrast, if you add them up, there were 2,227 babies born in hospitals who didn't make it past a month either. The rates for total mortality by place of birth including all birth attendants is 0.59 per thousand births for hospitals and 1.06 for "not in hospital".

Okay, then. Say we admit that, taking all comers, a baby is about twice as likely to die if born at home than in a hospital, or even three times as likely if attended by a lay midwife. Sounds pretty scary, no? Well, no.

It's the age old difference between absolute and relative risk. Take TBTAM's trick of using a piece of graph paper with 1,000 squares, and see what the difference is between having one square colored in, or two (or even three). Combine that with the tiny absolute numbers of women who want to give birth at home in the first place (I didn't want to have to clean up after it, frankly) and the whole thing starts looking more like the ideological witch hunt against midwifery that it actually is, and a whole lot less like a noble call to save large numbers of innocent babies from their mothers' intransigence.

News flash: people choose home birth over a hospital experience for many reasons, and will continue to do so even in the light of these statistics. Why? For the same reason they ride motorcycles, some of them without helmets. They feel that the advantages to them outweigh the risks. How can they best minimize the risk? By selecting a birth attendant with appropriate training and experience, for one. More training for midwives? I'm all in favor. But demonizing the entire home birth community by condemning their "Tragic Toll" is uncalled-for.

If you want to talk about "Tragic Tolls", Dr. Amy, check this out:
The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,760 child fatalities in 2007.
Now that's tragic.


At Thu Nov 05, 03:32:00 PM, Blogger Rebecca said...

What is interesting to me is that Dr. Amy seems to like to have it both ways. She concedes the results from, for example, the recent study of home vs. hospital perinatal mortality in the Netherlands, but claims that it's because the Netherlands has a system set up to ensure the safety of home births. But this is just more fodder for an argument against midwives in America, because they are practicing without the benefit of that system...not an argument that the American system needs to change.

At Thu Nov 05, 03:46:00 PM, Anonymous T4 said...

Then again, 'even' in the Netherlands home birth is a subject of debate in the medical journals and magazines on a regular basis; though home births are still regarded as quite safe by the public at large. I agree with you that the choice of home birth over hospital birth is based on more than just statistics.

At Fri Nov 06, 12:40:00 PM, Blogger Amanda said...

Very interesting post, thank you for a different view on the statistics. Dr. Amy has never been on of my favorite blogs, the fact that she fairly allows a "middle ground" irritates me. Here's the thing about statistics, as my research and stats prof said, "You can make stat #'s say anything you want them to say. It's all in how you phrase and present the numbers."

At Fri Nov 06, 01:00:00 PM, Anonymous tom said...

Dino, excellent call-out of an obviously biased perspective. I particularly like the link to the child fatalities.

Any chance economics is the true concern?

What about of Dr. Amy were able to utilize CNM's like CRNA's? Multiply her ability to earn,
without having to do the work?

btw, when are you going to go "cash" or have youdone so and I missed it?

At Fri Nov 06, 08:24:00 PM, Anonymous Anonymous said...

Interesting points. However, in my young days I delivered babies (most FPs did. I have seen things turn on a dime far too often, even in previously normal pregancies and deliveries to ever want anybody I cared about to attempt a delivery at home, no matter who was attending them. I have nothing against midwives, my grandson was delivered by a CNM. In a hospital. With a doctor available.

At Sat Nov 07, 06:02:00 PM, Anonymous red rabbit said...

I have to admit, I am a little surprised. I wouldn't have thought you'd land on that side of homebirths. There is so much misinformation, and the homebirth midwives in my limited experience are quite often the ones promulgating it- including the antivaccinery and the you-failed-as-a-woman-if-you-needed-epidural stuff.

Around here, we have midwives delivering in-hospital with MD surgical and anaesthesia backup. The rooms are large, separate from the rest of the hospital, quiet, and private. There are private showers and baths and music and easy chairs and space for the whole flag-football team if you want them present.

This generally works but there are occasions when the midwives allow a bad situation to go far too far before calling for backup. I can't imagine what they get up to outside of a hospital.

At Sun Nov 08, 04:37:00 PM, Blogger Yehudit said...

What's really lacking is an attempt to separate out the inherent risks associated with place of birth from other issues (for example, the training or the woo-flavoured ideological commitments of home birth attendants). A very quick look at other places on the planet shows that midwives working in community settings can have the same standard of training and same outlook as hospital-based providers (indeed, in the UK there are places that organize their midwifery workforce to rotate in and out of hospital/community on a regular basis).

At Mon Nov 09, 07:24:00 AM, Anonymous Anonymous said...

I read your last line as "Tragic TROLLS," and thought, "Yeah, that's about right for Dr. Amy."

At Mon Nov 09, 08:04:00 AM, Blogger Kay said...

When I was growing up the house next door to mine was turned into a midwife birthing and care center. It was the only one in my county and I saw many, many women pass through its doors. As a dedicated facility it seemed to be a middle ground between a true home birth and a hospital birth.

But it takes just one horrible example to skew your viewpoint forever. Red Rabbit's comment was especially chilling for me. "This generally works but there are occasions when the midwives allow a bad situation to go far too far before calling for backup. I can't imagine what they get up to outside of a hospital."

When I was pregnant with my first child, a neighbor of mine -- a delivery room nurse (!) -- said that she would never give birth in a hospital again, and chose to have her second child at home with just a midwife. The cord was wrapped around the baby's neck, and midwife waited too long to call for backup. The baby lived, but with permanent severe brain damage.

I had both of my children in a hospital.

At Tue Nov 10, 06:51:00 PM, Anonymous Anonymous said...

Adding to the point of not correcting for confounding factors. I would suspect that the reason the miswife has lower mortality than the MDs in a hospital is that with all ability to monitor a fetus today, the midwives don't get as many births that are known to be risky ahead of time. Therefore, there is probably a selection bias in those statistics.

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At Wed Nov 25, 10:53:00 PM, Blogger FairFlowers said...

Thanks for the balanced perspective, Dino.
You know, as a licensed direct entry midwife, there are times when I wish I could work with an OB for a day or two and ask them questions. Simply by seeing so many women and so many births, they are a wealth of information about oddball stuff that may come up in pregnancy and birth. I think it would be very helpful to me and my practice.
However, I think it would also be very helpful to most obstetricians to work with a direct entry midwife for a day and a birth or two and to observe our practices. I think they would learn a lot that would be helpful to them and their practice.
So many of the women I see who choose home birth do so because of previous unhappy experiences with OBs or hospital birth. And yet, I have seen absolutely wonderful, sensitively managed births in the hospital.
For me, what it boils down to is that NO ONE can promise you a perfectly safe birth no matter where you have it. There are trade-offs and risks whether you are in the hospital, birth center or home. You have to decide what you are personally comfortable with. Not Dr. Amy, not the government, not your mother-in-law. YOU.
I would never try to push someone into a home birth if they weren't comfortable with it. And there is a time and a place for a trained OB at birth. Thank God they are available when needed. (and for the ones I know who are open-minded to my practice.)

At Fri Dec 04, 05:23:00 AM, Blogger Rogue Medic said...

One major confounder is that homebirths should never include high risk deliveries. Assuming that the midwives appropriately refer these high risk pregnancies to the hospital, then that dramatically skews the numbers.

This is also one of the reasons that the American infant mortality numbers look so bad. If you compare the US with a country that does not have the rate of high risk premature births, the superficial conclusion is that they are better at delivering babies safely. One constantly cited example is that Cuba looks good at delivering babies, while the US looks bad. Cuba is good at delivering babies in the same way that Bernie Madoff is good at managing money. As long as you don't mind a lot of fraud in the reporting of the numbers, you will love your Cuban delivery, or you may have to take a Mulligan.

The problem with home deliveries/birthing center deliveries is that if something goes wrong, you need to get to the hospital quickly.

I used to work at a hospital across the street and a couple hundred feet down the road from a birthing center. The nurses/midwives were great, but the ambulance was based on the other side of town, so there was a bit of a wait. I would show up and, to the surprise of the nurses/midwives, not start barking orders. They have far more experience at this than I ever will. Unfortunately, not all of my coworkers are as humble. My main job was moving furniture to allow easy stretcher access. Even though women will walk all through their pregnancies, when things go wrong, walking is generally not an option.

Delivery outside of the hospital is not an option in my family, since there probably has not been a vaginal delivery in over a century unless the baby was premature. Either way, this is not a recipe for survival in my family.

If you do want to deliver outside of a hospital, I strongly recommend being very close to the hospital, especially if it is a first pregnancy.


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